Is This Really Swelling Because It Was a Suture Area or is It Terrible Scar Tissue or Worse? Will It Go Away with Time? (photo)

Wow! 4 questions in 1 with only 2 question marks! Thanks for including photos; they are essential to see why you are understandably concerned.

Let's start at the beginning. You are 2 weeks post-op (as informed by your later comment), so the responses from my colleagues about waiting for at least weeks, but usually 4-6 months, and even up to a year are in fact correct. You ARE very early in the healing period and things will undoubtedly get better as time goes by. You would be right in asking about looking this bad for that length of time, because I do agree things do NOT look "normal" at this point in time.

I say this because I do lots of rhinoplasties (5 this past 9 work days, and 1 scheduled next week, for example) and have done rhinoplasty surgery for over 25 years. The majority of them are "open" like yours, with columellar incisions. None of them look like yours does, and in fact they all look better than yours even 1 week post-op, even in patients who tell me they heal with "bad scars." So, it is indeed possible that you simply heal with thick or hypertrophic scars. That's in your genetics, and there is nothing you or your surgeon can do about that. . .

 . . .except for your surgeon to understand that this is always a small but distinct possibility, and to use the most accurate and precise dissection, hemostasis, and technical accuracy with your surgical incision and closure. Thus, if better techniques were not used, you could end up with the "worse" scenario--bad healing tendencies PLUS poor technique!  Genetically "poor healing" occurs only in a very small proportion of patients, so this ends being simply an excuse all too often.

Unfortunately, though time does indeed improve even bad scars as healing progresses, swelling diminishes, and scar tissue softens, fades, and becomes less ghastly in appearance, it may not improve enough to be considered a satisfactory outcome. Sure, revision is possible, but if plan A didn't work out, do you really want second-best plan B?

I see a couple of things to comment on here. First of all, your closure seems to approximate the skin edges reasonably well, but there are too many sutures (at least 8, and 6 more notching the soft triangle area of the anterior nostril rim skin) and they are tied too tightly. They also look like dissolving catgut sutures, though I cannot tell this precisely by your photograph, only infer this from the nearly absent suture tails (removable sutures would have "tails" to be grasped for removal). Most self-absorbing sutures "dissolve" by hydorlysis (synthetic suture materials), but catgut sutures "dissolve" by proteolysis, a more inflammatory process. More inflammation--more scarring. Tie them too tightly and strangulation of the tissues occur, worse as swelling makes them "dig into" the tissues, where the inflammatory dissolving process causes more scar formation. Wait--I thought we wanted a good scar!

So how could this have been done better? Since all of the skin swelling in your incisional area is anterior to the scar, it is evident that the skin of the columella posterior to the incision was never dissected from the underlying cartilage as was the skin anterior to the incision (where the nasal skin was ultimately lifted from the underlying cartilages to work on them). I believe that POSTERIOR columellar skin dissection should always be carried out (even if there is no anticipated surgical "work" needed in that location), simply to equalize the post-operative swelling and provide a smooth caudal columellar line. Both in front of and behind the scar will swell to the same degree and resolve at the same rate, and the skin never looks "hanging" in front, and flat behind the scar. When only anterior dissection is done, even a good scar looks worse because of this visible swelling discrepancy and stepoff which takes those weeks, months, or even up to a year to equalize and settle!

And, of course, a single well-placed (synthetic absorbable) subdermal suture will take all tension off the surface skin sutures, and no more than 4 (monofilament non-absorbable) surface skin sutures should be tied loosely enough that swelling does not cause them to "dig into" the skin. They should be removed in 5-7 days, and be covered with Bacitracin for the first day or two to minimize bacterial contamination from nasal mucous or drainage (common after rhinoplasty). 

I have taken the time to type all of this out because I see it as a failure of adhering to BASIC PLASTIC SURGICAL PRINCIPLES! This is nothing you did wrong, and your surgeon appears to have given you a good rhinoplasty result, and then "fell down" on the closure! I tell you this not to make you feel ill towards your surgeon but to (perhaps not-so-gently) remind my colleagues that even the most skillfully-performed rhinoplasty and wonderful result can be undone by a less-than-ideal closure. Did the surgeon's scrub nurse, suture tech, medical student, or resident do the closure after a stellar rhinoplasty? Or did your surgeon simply do a "routine closure" with sutures chosen so they didn't require removal, tied too tightly to "make sure they hold," and a "few extra" to tug the swollen skin on the front side of the incision to the not-swollen skin behind it?

I'm trying not to sound "preachy" or pompous in my pronouncements, but I truly believe that this could have simply been better dissected to equalize the swelling, closed with fewer stitches and less inflammation-producing suture material, and tied less tightly and removed sooner to avoid this appearance. It will get better, but looking like this and feeling bad about it for as long as it is liable to take is a huge bummer, and one I truly believe is in the power of the surgeon to avoid in most cases. This is not even close to negligence or malpractice; it just could have been done better, in my opinion. I say this with the full knowledge that I too have imperfect closures and some bad scars, just none from failure to adhere to these simple and basic principles. I am sorry your otherwise good result is marred by this. Dr. Tholen

If your stitches are still in place, it is quite early to be concerned about the appearance of your columella following an open rhinoplasty. When performed correctly by a skilled surgeon, a columellar incision will leave a scar that is minimally visible. In general, a columellar scar will:

1) Fade over time
2) Benefit from scar gel

It is too soon to have scar tissue develop in the area. What you are experiencing will likely improve with time, and appears to be a result of swelling. I hope this helps, and I wish you the best of luck.

With adequate healing time the appearance of the columellar scar should improve as the swelling settles down. Try and be patient. If the scar is more visible than desired after adequate time has passed, you can consider scar revision, which can likely be done under local anesthesia.